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Policy No.:______________
Date:____________________
Dear Sir,
I understand that my aforementioned policy is being foreclosed and the surrender value of
Rs._______________________ will be refunded to me as per the policy terms & conditions.
______________________________________
Signature of the Policy Holder
________________________________
Date (DD/MM/YYYY)
AttachCancelledCheque Here
AttachCancelledChequeHere
Policy holders signature to be taken on cancelled cheque. Cancelled cheque should bear the name of the policyholder/account holder's
name & IFSC / RTGS / NEFT Code. In the absence of these details, the applicant needs to submit a recent bank statement of the same
Bank Account. The bank a/c number should be clear & visible (please do not cross on a/c no.). If such details are not available direct
transfer would not be an option.
Reliance Life Insurance Company Limited. (Reg. No. 121)
Registered Office:-H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710, India
Corporate Office- 9th & 10th Floor, Building No 2, R-Tech Park, Nirlon Compound, Goregaon (East) Mumbai 400063, India.
Phone No- 1800 300 08181/30338181 Email: rlife.customerservice@relianceada.com Website: www.reliancelife.com
Terms & Conditions:
1)
RLIC shall not pay any money against surrender in the form of Cash
2)
If the electronic credit is not effected, delayed or credited to a wrong account on account of incorrect or
incomplete information provided, RLIC shall not liable for such losses.
3)
Surrender charges as mentioned in the terms & conditions of the policy document is applied.
4)
5)
6)
All the above requisitions shall be processed as per the terms & conditions as laid in the policy contract & will
be binding.
I understand and agree to all the above terms and conditions as referred above.
_________________________
________________
SignatureofthepolicyHolder
(DD/MM/YYYY)
****************************************************************************************************
Signature is in Vernacular, please complete the following declaration:
I hereby declare that I have fully explained/translated the contents mentioned in the payout form to (Name of policy
owner) and I further declare that he/she/they fully understood the meaning thereof.
___________________
________________
Signature of declarant
Date (DD/MM/YY)
Name & Address of declarant________________________________________________________________________
I hereby confirm that I have been explained the contents in -_____________________________ (Language) and have
understood the same.
__________________
Date (DD/MM/YY)
Given Account No matches with Account No in the attached Cancelled Cheque/Bank Statement
Request Time Stamp Affixed
___________ ______Date:_________________